Difficult Contexts Research Articles

How to make smoking prevention work for vulnerable populations: insights from French project DCAP

Abstract Issue Smoking prevention interventions tend to reach with difficulty young people and disadvantaged groups in France. Yet, limited research provides practical evidence detailing tobacco prevention interventions (TPI) aimed at them. Documenting the practical experience of health promotion, social and education workers tackling this issue is therefore crucial. To that end, the French Society for Public Health designed and carries out a project to CAPitalize experiential Data on TPI: DCAP. DCAP Initiated in 2019, DCAP consists in capitalizing, i.e. collecting, documenting and circulating, experiential knowledge from practitioners who implement TPI at the local level for young people and vulnerable people. Goals include building up original knowledge from field actions, documenting how TPI unfold in various contexts and take into account health inequalities, and supporting professional practices. DCAP follows 3 main steps: 1/identifying promising TPI, 2/ documenting selected TPI and the key mechanisms impacting how TPI unfold (context, partnerships, barriers and levers, ethics), 3/ sharing knowledge built up on TPI, via an online portal. Results DCAP will document 40 interventions total. Preliminary results, based on TPI documented in 2019, highlight experiential knowledge built up to face 3 types of Issues 1/building and sustaining partnerships for long-term TPI programs, between health professionals, schools and parents for example, 2/building support for TPI in difficult contexts: prisons, emergency housing, etc. 3/innovating and inventing collective TPI adjusted for disadvantaged groups. Insights also emerge on current trends. For example, programs for young people tend nowadays to favor global approaches to addiction prevention over smoking prevention alone. Lessons Most TPI remain confidential yet form a rich corpus of original and practical evidence other stakeholders can benefit from. Future research projects can also benefit from the data collected through DCAP. Key messages Documenting the practical experience health promotion, social and education workers hold is crucial to share knowledge and implement tobacco prevention interventions that work for vulnerable people. DCAP details key mechanisms in smoking prevention interventions aimed at vulnerable groups in France, including long-lasting partnerships building and innovative collective formats design.

Health promoting pharmacies in Northern-Italy: more than drugstores

Abstract Issue In Friuli Venezia-Giulia Region (Italy), accessibility to health services can be substantially influenced by the geographical context. In fact, during recent years, at-risk inhabitants of mountain villages were less likely to be vaccinated against flu in comparison with other areas. To tackle inequalities, local pharmacies were identified as a proximity health promotion network to be engaged in the 2019/2020 flu vaccination campaign. Description Within the mountainous Carnia District, 43 pharmacists from 25 pharmacies were trained before the campaign to promote flu shot uptake through counseling in over 65 and high-risk subjects. After counseling, subjects were directed to General Practitioners who performed vaccine administration and registration. Anti-flu counseling offered by pharmacists was traced and vaccine coverage against influenza among target categories was considered as the principal outcome. A reward was granted to pharmacies in relation to flu vaccine conversions among counseled subjects. Results Between October 2019 and January 2020, a total of 2,748 counseling sessions with people accessing pharmacies for any reason were conducted. Within Carnia District, flu vaccine was administered to 6,484 out of 10,895 (59.5%) over 65 subjects in comparison with 5,569/10,251 (54.3%) who got their flu shot during the 2018/19 flu season, achieving an improvement of + 5.2%. This result exceeded the regional global outcome reaching +2.2%, being the best among all districts. In particular, in comparison with the previous year, +10.2% over 65 and +37.8% at-risk subjects were vaccinated against flu in Carnia District. Lessons Pharmacies played an important role in promoting flu vaccination locally, and proved their potential contribution in tackling inequalities related to difficult contexts. The collaboration of health professionals, including pharmacists, should be taken into consideration to improve health promotion and health services access. Key messages Pharmacies are trustworthy healthcare system access points for people, therefore their role in health promotion should be fostered. Pharmacists can help in improving flu shot uptake in contexts where health service access is hindered.

Developing and evaluating packages to support implementation of quality indicators in general practice: the ASPIRE research programme, including two cluster RCTs

BackgroundDissemination of clinical guidelines is necessary but seldom sufficient by itself to ensure the reliable uptake of evidence-based practice. There are further challenges in implementing multiple clinical guidelines and clinical practice recommendations in the pressurised environment of general practice.ObjectivesWe aimed to develop and evaluate an implementation package that could be adapted to support the uptake of a range of clinical guideline recommendations and be sustainably integrated within general practice systems and resources. Over five linked work packages, we developed ‘high-impact’ quality indicators to show where a measurable change in clinical practice can improve patient outcomes (work package 1), analysed adherence to selected indicators (work package 2), developed an adaptable implementation package (work package 3), evaluated the effects and cost-effectiveness of adapted implementation packages targeting four indicators (work package 4) and examined intervention fidelity and mechanisms of action (work package 5).Setting and participantsHealth-care professionals and patients from general practices in West Yorkshire, UK.DesignWe reviewed recommendations from existing National Institute for Health and Care Excellence clinical guidance and used a multistage consensus process, including 11 professionals and patients, to derive a set of ‘high-impact’ evidence-based indicators that could be measured using routinely collected data (work package 1). In 89 general practices that shared data, we found marked variations and scope for improvement in adherence to several indicators (work package 2). Interviews with 60 general practitioners, practice nurses and practice managers explored perceived determinants of adherence to selected indicators and suggested the feasibility of adapting an implementation package to target different indicators (work package 3). We worked with professional and patient panels to develop four adapted implementation packages. These targeted risky prescribing involving non-steroidal anti-inflammatory and antiplatelet drugs, type 2 diabetes control, blood pressure control and anticoagulation for atrial fibrillation. The implementation packages embedded behaviour change techniques within audit and feedback, educational outreach and (for risky prescribing) computerised prompts. We randomised 178 practices to implementation packages targeting either diabetes control or risky prescribing (trial 1), or blood pressure control or anticoagulation (trial 2), or to a further control (non-intervention) group, and undertook economic modelling (work package 4). In trials 1 and 2, practices randomised to the implementation package for one indicator acted as control practices for the other package, and vice versa. A parallel process evaluation included a further eight practices (work package 5).Main outcome measuresTrial primary end points at 11 months comprised achievement of all recommended levels of glycated haemoglobin, blood pressure and cholesterol; risky prescribing levels; achievement of recommended blood pressure; and anticoagulation prescribing.ResultsWe recruited 178 (73%) out of 243 eligible general practices. We randomised 80 practices to trial 1 (40 per arm) and 64 to trial 2 (32 per arm), with 34 non-intervention controls. The risky prescribing implementation package reduced risky prescribing (odds ratio 0.82, 97.5% confidence interval 0.67 to 0.99;p = 0.017) with an incremental cost-effectiveness ratio of £2337 per quality-adjusted life-year. The other three packages had no effect on primary end points. The process evaluation suggested that trial outcomes were influenced by losses in fidelity throughout intervention delivery and enactment, and by the nature of the targeted clinical and patient behaviours.LimitationsOur programme was conducted in one geographical area; however, practice and patient population characteristics are otherwise likely to be sufficiently diverse and typical to enhance generalisability to the UK. We used an ‘opt-out’ approach to recruit general practices to the randomised trials. Subsequently, our trial practices may have engaged with the implementation package less than if they had actively volunteered. However, this approach increases confidence in the wider applicability of trial findings as it replicates guideline implementation activities under standard conditions.ConclusionsThis pragmatic, rigorous evaluation indicates the value of an implementation package targeting risky prescribing. In broad terms, an adapted ‘one-size-fits-all’ approach did not consistently work, with no improvement for other targeted indicators.Future workThere are challenges in designing ‘one-size-fits-all’ implementation strategies that are sufficiently robust to bring about change in the face of difficult clinical contexts and fidelity losses. We recommend maximising feasibility and ‘stress testing’ prior to rolling out interventions within a definitive evaluation. Our programme has led on to other work, adapting audit and feedback for other priorities and evaluating different ways of delivering feedback to improve patient care.Trial registrationCurrent Controlled Trials ISRCTN91989345.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 8, No. 4. See the NIHR Journals Library website for further project information.

EasyPrimer: user-friendly tool for pan-PCR/HRM primers design. Development of an HRM protocol on wzi gene for fast Klebsiella pneumoniae typing

In this work we present EasyPrimer, a user-friendly online tool developed to assist pan-PCR and High Resolution Melting (HRM) primer design. The tool finds the most suitable regions for primer design in a gene alignment and returns a clear graphical representation of their positions on the consensus sequence. EasyPrimer is particularly useful in difficult contexts, e.g. on gene alignments of hundreds of sequences and/or on highly variable genes. HRM analysis is an emerging method for fast and cost saving bacterial typing and an HRM scheme of six primer pairs on five Multi-Locus Sequence Type (MLST) genes is already available for Klebsiella pneumoniae. We validated the tool designing a scheme of two HRM primer pairs on the hypervariable gene wzi of Klebsiella pneumoniae and compared the two schemes. The wzi scheme resulted to have a discriminatory power comparable to the HRM MLST scheme, using only one third of primer pairs. Then we successfully used the wzi HRM primer scheme to reconstruct a Klebsiella pneumoniae nosocomial outbreak in few hours. The use of hypervariable genes reduces the number of HRM primer pairs required for bacterial typing allowing to perform cost saving, large-scale surveillance programs.

Healthcare professionals' views on supporting young mothers with eating and moving during and after pregnancy: An interview study using the COM-B framework.

Young mothers under the age of 20 often have poor nutrition and low levels of physical activity, adversely affecting outcomes for themselves and their babies. The aim of this qualitative study was to explore the experiences of healthcare professionals in supporting young women around eating and moving during and after pregnancy. Seventeen semi-structured interviews were conducted with midwives, family nurse practitioners and health visitors involved in the care of pregnant and post-natal mothers under the age of 20 in England and Wales. Data were analysed using thematic analysis and coded within the theoretical framework of the COM-B model to three areas of capability, motivation and opportunity. For capability, participants were broadly divided between those who had specialist knowledge and training in communication skills to support health behaviours in this population and professionals reliant on tacit knowledge. For opportunity, having enough time was seen as critical because young women's difficult social contexts meant supporting improved health behaviours required relationships of trust to be built. For motivation, participants reported that supporting young women with eating and moving was part of their role. However, the decision to prioritise this support sometimes related to perceived need based on BMI and this was complicated as young women were still growing. Motivation was additionally connected to professionals' own body experiences and health behaviours. Moving habits were less frequently discussed than eating as professionals described how young women tended to walk a lot in their daily lives or found that young women were not interested. Results suggest that to support eating and moving behaviours with young women, professionals need to be trained in communication techniques, enabled with the time to hold space for young women and be able to reflect on their own attitudes and beliefs to support a rounded model of health and wellbeing.

Stereotyping as a barrier to the social participation of older adults with low vision: a qualitative focus group study

ObjectiveIn order to better understand the barriers that limit the social participation of older people with low vision, the aim of this study was to describe and clarify the factors...

From Space to Supply Chains: A Plan for Humanitarian Data Governance

In June of 2019, the World Food Programme (WFP) issued an ultimatum to the Houthi Government in Yemen: participate in our biometric identification system or receive less aid. The Houthis chose to a partial stoppage of aid, accusing the WFP of being a surveillance operation. The issue is complicated – on both sides – but it points to a significantly larger trend: humanitarian organizations’ digital operations and data sharing relationships increasingly shape whether beneficiaries, governments, and partners trust them. And, for humanitarian organizations, trust determines their license to operate, which is often negotiated with a range of parties in difficult contexts. At a practical level, humanitarian organizations digital transformations aren’t just changing response efforts – they’re also changing the role of humanitarian organizations themselves, from direct service providers to managing a network of digital vendors, public/private partnerships, local partners, and governments – and all of their competing interests in the data response efforts produce. Humanitarian organizations are increasingly in the position of negotiating the license to operate, including to collect and share data, without the ability to enforce those licenses across their supply chains. As a result, one of the clearest opportunities to protect shrinking humanitarian space is to focus on building transparent data management and governance into humanitarian supply chain contracting. This article highlights the relationship between digitization and humanitarian supply chains, with a focus on data protection and governance, and makes concrete recommendations on where to focus reform efforts to meet practical needs of digital humanitarianism.

Neighborhood-conditioned phonetic enhancement of an allophonic vowel split.

Vowels are enhanced via vowel-space expansion in perceptually difficult contexts, including in words subject to greater lexical competition. Yet, vowel hyperarticulation often covaries with other acoustic adjustments, such as increased nasal coarticulation, suggesting that the goals of phonetic enhancement are not strictly to produce canonical phoneme realizations. This study explores phonetic enhancement by examining how speakers realize an allophonic vowel split in lexically challenging conditions. Specifically, in US English, /æ/ is raising before nasal codas, such that pre-nasal and pre-oral /æ/ are moving apart. Speakers produced monosyllabic words varying in phonological neighborhood density (ND), a measure of lexical difficulty, with CæN or CæC structure to a real listener interlocutor in an interactive task. Acoustic analyses reveal that speakers enhance pre-oral /æ/ by lowering it in Hi ND words; meanwhile, pre-nasal /æ/ Hi ND words are produced with greater degrees of nasalization and increased diphthongization. These patterns indicate that ND-conditioned phonetic enhancement is realized in targeted ways for distinct allophones of /æ/. Results support views of hyperarticulation in which the goal is to make words, that is, segments in their contexts, as distinct as possible.

A social-ecological analysis of drinking water risks in coastal Bangladesh

Groundwater resources in deltaic regions are vulnerable to contamination by saline seawater, posing significant crisis for drinking water. Current policy and practice of building water supply infrastructure, without adequate hydrogeological analysis and institutional coordination are failing to provide basic drinking water services for millions of poor people in such difficult hydrogeological contexts. We apply a social-ecological systems approach to examine interdisciplinary data from hydrogeological mapping, a water infrastructure audit, 2103 household surveys, focus group discussions and interviews to evaluate the risks to drinking water security in one of 139 polders in coastal Bangladesh. We find that increasing access through public tubewells is common but insufficient to reduce drinking water risks. In response, there has been a four-fold growth in private investments in shallow tubewells with new technologies and entrepreneurial models to mitigate groundwater salinity. Despite these interventions, poor households in water-stressed environments face significant trade-offs in drinking water quality, accessibility and affordability. We argue that institutional coordination and hydrogeological monitoring at a systems level is necessary to mitigate socio-ecological risks for more equitable and efficient outcomes.

Service Delivery Reform in Nigeria: The Rise and Fall of the Conditional Grant Scheme to Local Government Areas (CGS to LGAs)

This paper analyses Nigeria’s Conditional Grant Scheme to Local Government Areas (CGS to LGAs). It tracks the design and implementation of CGS to LGAs at multiple levels, with a conceptual focus on the dynamics of state capacity and elite commitment. The paper finds that, while considerable progress was made initially with reforms, the increase in patronage politics following the change in national political leadership in 2011 meant that reforms were not sustained. At the local level, the scheme partly achieved its objectives, as in Guri LGA, where an informal development coalition seized the opportunity to increase spending and improve LGA capacity to deliver basic education and health services. The reforms were less effective in other LGAs, such as Mashi, where pre-existing factors, especially elite capture and frequent turnover of civil servants, undermined reforms. Even in difficult governance contexts, service delivery programmes can be designed and implemented in a manner that is both technically adequate and politically smart to achieve better development outcomes. However, sustaining such gains requires the continued commitment of political and bureaucratic elites along the implementation chain.

Fathering Within Transnational and Mixed-Status Mayan Families: An Exploratory Study

This study explores fathering within a small sample of Mayan transnational and mixed-status families divided between the Northeastern United States and the Quiché region of Guatemala. A positive masculinities framework informs this theoretical thematic analysis of semistructured interviews with 7 migrant fathers and 2 sons-as-fathers who were caring for younger siblings in Guatemala. Analyses sought to illuminate how the performances of fathering in the context of migration depart from and sometimes challenge hegemonic conceptions of masculinities evident in much of the migration scholarship. In total, 5 themes capturing varying performances of fathering were identified: (a) staying-at-home, (b) emotionally expressing cross-border relationality, (c) communicating within the family about return and consejos (conventional wisdom), (d) sons-as-fathers caring for family members here and there, and (e) maintaining the household intergenerationally. We discuss how the transnationalizing of these Mayan families has contributed to more diverse gendered roles and relationships, with a focus on some of the potential positive influences of this process on family relationships. Implications for future research about the various ways in which fathers and sons contribute to their transnational families, especially in difficult sociopolitical contexts, are discussed.

Testimony Under Threat: Women\u2019s Voices and the Pursuit of Justice in Post-War Sri Lanka

This paper foregrounds how women’s public testimony as part of a formal transitional justice initiative is shaped by the particular context in which a commission operate, including the political and security environment. While the literature has engaged with the gendered predicaments of truth commissions after peace agreements and during transitions away from non-democratic rule, the function of such initiatives in more authoritarian and in immediate post-war contexts is generally overlooked. I examine women’s testimonies from Sri Lanka’s Lessons Learned and Reconciliation Commission (LLRC), and contend that pervasive militarization and insecurity, and the conduct of the Commission, influenced the stories that came forth. Women’s testimonies in the war-torn areas primarily represent pleas for information about missing family members and reflect important silences about the women’s own experiences of abuse, including ongoing post-war insecurities. The analysis raises questions about what may be expected from transitional justice efforts in difficult post-war contexts.

Intestinal NF-κB and STAT signalling is important for uptake and clearance in a Drosophila-Herpetomonas interaction model.

Dipteran insects transmit serious diseases to humans, often in the form of trypanosomatid parasites. To accelerate research in more difficult contexts of dipteran-parasite relationships, we studied the interaction of the model dipteran Drosophila melanogaster and its natural trypanosomatid Herpetomonas muscarum. Parasite infection reduced fecundity but not lifespan in NF-κB/Relish-deficient flies. Gene expression analysis implicated the two NF-κB pathways Toll and Imd as well as STAT signalling. Tissue specific knock-down of key components of these pathways in enterocytes (ECs) and intestinal stem cells (ISCs) influenced initial numbers, infection dynamics and time of clearance. Herpetomonas triggered STAT activation and proliferation of ISCs. Loss of Relish suppressed ISCs, resulting in increased parasite numbers and delayed clearance. Conversely, overexpression of Relish increased ISCs and reduced uptake. Finally, loss of Toll signalling decreased EC numbers and enabled parasite persistence. This network of signalling may represent a general mechanism with which dipteran respond to trypanosomatids.

The Myth of Protection: Gendering Protection under the Responsibility to Protect in Gaza

Although international norms on the Responsibility to Protect ( R2P ), norms stemming from United Nations Security Council Resolution 1325 and the agenda of Women, Peace and Security (wps) have shifted the narrative from a state-centric to a human-centric approach to security, they have failed to intersect in the most difficult contexts. This paper examines the intersections between Pillar iii of R2P, Resolution 1325 and the agenda of wps with a focus on protection in Gaza. Within the Gaza context, all authorities can be seen as failing in their responsibility to protect, however, no steps have been taken toward operationalisation of protection under R2P. Examining protection through a gendered lens provides a critical mirror of strategies of protection as well as a roadmap towards improvement. The article argues that R2P in combination with the agenda of wps provides a potential tool for constructing a consensus prioritising protection of civilians in the most difficult contexts.

Towards emotional containment for staff and patients: developing a Work Discussion group for play specialists in a paediatric ward

ABSTRACTThis paper describes the evolution of a staff Work Discussion group run by a child psychotherapist in a teaching hospital for more than 15 years. It offers insight into the emotional experience of both NHS staff and patients as seen through the lens of the discussion of the staff’s work. The author identifies three main stages in the evolution of this group, as trust and the feeling of a safe space gradually developed. The first stage was identifying and understanding the emotional experience of patients, through the use of observational skills and psychoanalytic concepts; the second emerged as staff began to include their own emotional experience in the narrative; the last stage saw a qualitative shift in the staff’s capacity to share the pain generated by the work, knowing about it through holding it in the group’s mind and being able to reflect on it, allowing them to process experience in a way that made the work more bearable – akin to Bion’s concept of ‘containment’. This evolution is illustrated with relevant vignettes in the light of some theoretical and historical considerations. The paper demonstrates the value of Work Discussion groups in terms of indirectly supporting hospitalised patients, as well as promoting staff’s resilience and professional capacities in difficult contexts.

Mothering at a distance and disclosure of maternal HIV to children in Kingston, Jamaica

AbstractExisting guidelines (WHO, 2011) advise caretakers and professionals to disclose children’s and their caretakers’ HIV status to children, despite a lack of evidence concerning the potential implications in resource-constrained settings. Our research uses feminist Interpretative Phenomenological Analysis (IPA) to explore the experiences of HIV positive mothers in Kingston, Jamaica, focusing on their lived experiences of talking to their children about maternal HIV. This paper will focus on the concept of mothering at a distance and how this presents additional challenges for HIV positive mothers who are trying to establish emotional closeness in relation to talking to their children about their HIV. Using Hochschild’s concept of emotion work and examples from the interviews, we highlight the difficult contexts informing women’s decisions when negotiating discussions about their HIV. Women may choose full, partial or differential disclosure or children may be told their mother’s HIV status by others. Disclosure policy, we argue, reflects Anglo-Northern constructions of the family and parenting which may not adequately reflect the experiences of poor urban mothers in low and middle income countries. We argue that policy needs to recognise culturally-specific family formations, which, in Jamaica includes absent fathers, mothering at a distance and mothering non-biological children. This article reflects on the experiences of an under-researched group, poor urban Jamaican women practising mothering at a distance, using a novel methodological approach (IPA) to bring into relief unique insights into their lived experiences and will contribute to the global policy and research literature on HIV disclosure.

La inclusión educativa y social desde la música y la palabra TITLE: Educational and social inclusion from music and the word

The educational and social inclusion of music and speech is aimed, on the one hand, at improving the most disadvantaged people, facilitating integration in their environment and in difficult contexts, and on the other hand, creating a training program in order to That students of primary level could contribute, from their experience and knowledge acquired in their training, a complementary practical application to students of similar characteristics and in environments of difficulty. This proposal is an initiative to be carried out in future cooperation projects and is based on the hypothesis that education can influence factors of resilience and social inclusion, using music and word as the backbone to avoid social and educational exclusion in adults. This project is part of the 10th Call for aid for research and training projects of the Permanent Observatory of Immigration (OPI-UJI).

Emotional Experiences and Reflexive Leadership Development

In this paper we ask: “What patterns of formational leadership learning are developed through reflexive engagement with emotional experience, and how do these patterns vary within the dimensions of individual versus dialogic engagement, and everyday versus confronting emotional experiences”? We employ a relationally reflexive method in which the authors take dual roles as researcher participants. We build on a framework of emotional experiences and reflexive learning that is comprised of: attention to emotions as triggers of reflexive practice; discussion, as reflexive engagement to explore and open up aspects of emotional experiences; transgression, experiencing extreme emotional experiences that disrupt everyday attention; and realization, recovering from traumatic circumstances through reflexive personal emotional work. We conclude that difficult emotional experiences are likely to have the potential to support useful leadership development learning, but learning from them requires resilience to ‘stay with’ distressing experiences longer than would be normal and that this can be aided by the engagement of others who are supportive, yet constructively critical. The leadership development lessons that can be supported may be closely tied to difficult contexts as the development of personal resources to cope with and lead others in coping with in similar traumatic circumstances. But perhaps more usefully, individuals may develop better practices of attention that enable them to address situations – at least sometimes – before uncontrolled, traumatic circumstances can unfold.

The Democratic Values of the Student Movement in Kosovo 1997/1999 and Their Echoes in Western Diplomacy

After the fall of east orientated political system and coming of the pluralistic system in the Yugoslav federation, the nationalisms that claimed to dominate Yugoslavia, such as Serbian, Croatian and Slovenian nationalism came to the surface, which also led to the overthrow of Yugoslavia. Following the abolition of Kosovo's limited autonomy of 1974, in March 1989, the Milosevic Serb regime during the 1990s imposed violent measures in all Kosovo institutions by removing Albanian workers from their jobs. Thus, Kosovo, Albanians were expelled collectively from the education process in the Albanian language, and left school and university facilities. Efforts to reach an agreement between Albanians and Serbian representatives for education during 1992 were unsuccessful. In these difficult contexts, the parallel education system of Kosovo Albanians was organized. In these difficult circumstances, students and Albanian students continued learning outside school facilities. After ignoring the Kosovo problem in the peace agreement reached in Dayton for Bosnia, the dissatisfaction with the peace policy led by Dr. Ibrahim Rugova grew all over Kosovo. In these circumstances, professors and students with vision began to talk about the organization of peaceful protests against the Serbian regime. After a long process, a new student movement took place at the University of Prishtina, which marks the beginning of the great protest on 1 October 1997. In this paper, we analyse the attitudes of international diplomacy with a special emphasis on the West in relation to this movement following the 1 October 1997 peace protests in Kosovo.

Powering institutions for development—Organizational strategies for decentralized electricity provision

The study addresses the question of how to achieve and sustain well-functioning local service delivery in institutionally difficult contexts, characterised by low levels of generalised trust, widespread corruption and poor institutions. We study a relatively successful case of decentralized electrification in Tanzania, and the process whereby an international NGO establishes a small-scale hydropower system with a local utility to own and operate it. Building on institutional theory, we investigate how to build trust in an organization, through a strategy of credible commitment; and how free-riding problems can be handled in a local development project. The qualitative study includes 119 semistructured interviews with project staff, villagers, and local and district government, observations and document analysis. The results indicate the importance of a positive ‘history of play’, sustained over time, and keeping distance from corrupt institutions, in order to build trust. Strict enforcement of rules was decisive for handling free riding behaviours, and impartiality in enforcement for perceptions of legitimacy and trustworthiness. Deviations undermined relations of trust. The results add nuance to more generic theoretical propositions and provide insights on un/intended consequences of institutional strategies. These are relevant for creating and sustaining local service organizations for electricity access and other public goods.